MEDICARE: DR. KONGSAK TANPHAICHITR M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RA0201X	Allergy & Immunology (Internal Medicine) Physician	35104	MO
2	207RR0500X	Rheumatology Physician	35104	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942362777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KONGSAK TANPHAICHITR M.D.

Provider Business Mailing Address
First Line	:	11115 NEW HALLS FERRY RD
Second Line	:	SUITE 102
City	:	FLORISSANT
State	:	MO
Zip	:	63033-7613
Country	:	US
Telephone Number	:	314-839-4339
Fax Number	:	314-839-0011

Provider Business Practice Location Address
First Line	:	11115 NEW HALLS FERRY RD
Second Line	:	SUITE 102
City	:	FLORISSANT
State	:	MO
Zip	:	63033-7613
Country	:	US
Telephone Number	:	314-839-4339
Fax Number	:	314-839-0011

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	08/03/2012

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Directions to “ DR. KONGSAK TANPHAICHITR M.D.” Practice Location

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